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Maintenance immunosuppressive therapy in renal transplantation in adults

Karen Hardinger, PharmD, BCPS
Daniel C Brennan, MD, FACP
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Albert Q Lam, MD


Maintenance immunosuppressive therapy is administered to almost all renal transplant recipients to help prevent acute rejection and the loss of the renal allograft. Although an adequate level of immunosuppression is required to dampen the immune response to the allograft, the level of chronic immunosuppression is slowly decreased over time (as the risk of acute rejection decreases) to help lower the overall risk of infection and malignancy; these risks directly correlate with the degree of overall immunosuppression. The type of immunosuppression may also be varied to decrease the risk of developing chronic allograft nephropathy (CAN), the most common underlying long-term cause of allograft loss. (See "Chronic renal allograft nephropathy".)

The optimal maintenance immunosuppressive therapy in renal transplantation is not established. The major immunosuppressive agents that are being used in various combination regimens are corticosteroids (primarily oral prednisone), azathioprine, mycophenolate mofetil (MMF), mycophenolate sodium (Myfortic), cyclosporine (in standard form or microemulsion), tacrolimus, everolimus, rapamycin (sirolimus), and belatacept [1-3].

In the United States, approximately 85 percent of transplant recipients were discharged on tacrolimus and mycophenolate, either with (58 percent) or without (42 percent) glucocorticoids [4].

Conventional maintenance regimens consist of a combination of immunosuppressive agents that differ by mechanism of action. This strategy minimizes morbidity and mortality associated with each class of agent while maximizing overall effectiveness. Such regimens may vary by transplant center and geographic area.

The regimens and agents used for maintenance immunosuppression following renal transplantation will be reviewed herein. A discussion of induction therapy in renal transplantation is presented separately. (See "Induction immunosuppressive therapy in renal transplantation in adults".)


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